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A nurse is reinforcing teaching to the parent of a 6 year-old with a urinary tract infection on how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply.
- A. I just bought my child new nylon panties.
- B. I will make sure my child does not hold urine.
- C. I will not give my child any more bubble baths.
- D. I will teach my child to wipe from the front to the back.
- E. I will use antibacterial soap for bathing my child.
Correct Answer: B,C,D
Rationale: Nylon panties can trap moisture, increasing infection risk; cotton is preferred. Not holding urine prevents bacterial growth. Avoiding bubble baths reduces irritation. Wiping front to back prevents bacterial spread. Antibacterial soap may disrupt natural flora, increasing infection risk.
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The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should
- A. Observe the child's behavior on at least 2 occasions
- B. Consult with the teacher about how to control impulsivity
- C. Compile a history of behavior patterns and developmental accomplishments
- D. Compare the child's behavior with classic signs and symptoms
Correct Answer: C
Rationale: Compile a history of behavior patterns and developmental accomplishments. A comprehensive history is essential for accurate ADHD diagnosis.
The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?
- A. Assist the client to the shower and provide directions to use antibacterial soap
- B. Delay the bath until the client has received antibiotic therapy for 24 hours
- C. Use a bath basin with warm water and a new washcloth for each body area
- D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client
Correct Answer: D
Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply.
- A. No sexual activity for at least 6 weeks postoperatively
- B. Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site
- C. Refrain from lifting objects weighing >5 lb (2.25 kg) until approved by the HCP
- D. Take a shower daily without soaking chest and leg incisions
- E. Use lotion on incision sites when changing dressing if the areas are dry
Correct Answer: B,C,D
Rationale: Reporting infection signs , weight restrictions , and daily showers are correct. Sexual activity can resume earlier if stable, and lotion is not routine.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.